How to ensure patients get the right care at the right time

Rotherham foundation trust chief nurse Jackie Bird has a problem most in her position share: “As an acute trust we are not getting the flow of patients out of the hospital right. We believe that is because we do not have the right level of care outside in the community.”

Kath Henderson, her counterpart in Rotherham community health services, the local primary care trust’s community services provider arm, agrees.

“We have care and we have skills but not at the right levels,” she says.

Rotherham is addressing this as a health and social care community in a pilot project with US computer giant McKesson, best known in the UK for its work on the electronic staff record.

Along with the local council social services department, Rotherham foundation trust and Rotherham community health services are now piloting McKesson’s appropriateness of care tool, InterQual. Not only is it helping clinicians to improve discharge plans for individual patients, it is providing evidence to support service redesign.

In the first 16 weeks the project pinpointed 1,574 days when acute beds were occupied by patients who would have been better off in a sub-acute care environment (see graphs).

Right place, wrong time

InterQual was developed in the US and is used around the world by more than 5,000 organisations to determine whether patients are in the right place for the treatment they need. Health insurers use it to inform their decisions about what they will pay for.

Last year, McKesson adapted it for use in the UK with the idea that it could inform decisions about appropriateness of care in the NHS.

Broadly, InterQual helps case managers assess individual patients’ symptoms against a vast database of validated clinical evidence. The tool allows them to judge whether a patient really needs acute care or whether they would be better off in, say, an intermediate care setting or indeed at home. In the community, it can be used to judge what a patient needs to stay at home safely or whether a patient needs admission.

Rotherham began to pilot InterQual in February 2009. The acute trust appointed case managers to use it in three wards initially (care of older people, trauma and orthopaedics, and emergency admissions) with a general and respiratory medicine ward coming online in May 2009.

Two more case managers have been appointed to roll out to unscheduled care in August.

Liz Cowley, a physiotherapist by training, is the case manager for an acute medical ward. She assesses patients against InterQual’s admission or continued stay criteria as appropriate. Where these show that a different care environment is needed, she works with the ward team and community services to smooth the patient’s path through the system.

“Having the assessment and realising that a patient does not need to be here triggers you to think,” she says. “Instantly you feel you have made a massive difference to someone being able to go home.”

The case managers have found they can mobilise services everyone assumed were impossible to provide. In one case, the community team was able to supervise intravenous antibiotic treatment for a patient; in another social services provided a care package against all expectations.

Data for managers

InterQual is also designed to be a powerful management tool. The assessments can be anonymised and aggregated, giving managers and commissioners hard information about how appropriate - or otherwise - their bed use is.

Carole Lavelle, project lead at Rotherham foundation trust, is cautious about sharing data, pointing out various caveats about early days and data quality. The initial results from four wards are at first sight quite startling, showing that 77 per cent of patients do not need to be on the acute wards.

For many, this is because the appropriate alternatives needed to support them are not currently available locally - confirming Ms Bird and Ms Henderson’s suspicion. The data is now helping to redefine what the health community requires to support patients who do not really require acute level care. For the first time, hard data is available to help inform planning and decision making.

For a start, Ms Bird is using the data to develop a business plan for a new sub-acute unit within the hospital. Longer term, Ms Henderson says it may be used to inform the transforming community services agenda in Rotherham, helping commissioners to make a case for taking resources out of the acute trust to build up community services. Yes, she admits, this is a paradox: the two co-operating on a pilot that will ultimately arm them with the information they need to compete with each other.

“But at the heart of this we all share one idea: improving the health of the people of Rotherham. That’s really what is driving this.”